analysis of mandibular position using different methods of location

155
ANALYSIS OF MANDIBULAR POSITION USING DIFFERENT
METHODS OF LOCATION
Farley Augusto Venturelli, Paulo Renato Junqueira Zuim,
Rosse Mary Falcón Antenucci, Alício Rosalino Garcia
Department of Dental Materials and Prosthodontics, Araçatuba School
of Dentistry – São Paulo State University, Brazil
ABSTRACT
There has been much discussion regarding the ideal position of
the condyle in the mandibular fossa. Although the centric relation position (CR) is used as a reference, some authors do not
believe that it is physiologic. Thus, the aim of this study was to
evaluate in a group of asymptomatic individuals the position of
the condyle in the mandibular fossa at maximum intercuspation (MI), with a occlusal splint and with a Lucia jig between
the teeth. It was analyzed by means of magnetic resonance
imaging (MRI), transcranial radiography imaging and analysis of horizontal axis of rotation from casts mounted on an
articulator. The results showed that even if patients had
mandibular displacement in positions of CR, habitual maximum intercuspation and with the occlusal splint, confirmed by
means of the analysis of the horizontal axis of rotation, the
images showed no statistically significant differences among
condylar positions. It can therefore be concluded that the positions analyzed were similar and that transcranial radiography
seems to be a reliable method for analyzing condylar position.
Key words: condylar position, magnetic resonance imaging,
centric relation.
ANÁLISE DA POSIÇÃO MANDIBULAR ATRAVÉS DE DIFERENTES MÉTODOS
DE LOCALIZAÇÃO
RESUMO
Muito se discute sobre a posição ideal que o côndilo deve ocupar dentro da fossa mandibular. Apesar da Relação Cêntrica
(RC) ser usada como uma referência, alguns autores não concordam que esta posição seja fisiológica. Sendo assim, o
objetivo deste estudo foi avaliar a posição do côndilo dentro
da fossa mandibular em um grupo de indivíduos assintomáticos nas posições de máxima intercuspidação (MI), com placa
estabilizadora e com o Guia de Lucia, interposto entre os
dentes. A análise foi realizada por meio de imagem por
ressonância nuclear magnética, da radiografia transcraniana;
e análise do eixo horizontal de rotação, a partir de castos mon-
tados em articulador. Os resultados mostraram que, apesar de
os pacientes possuírem deslizes mandibulares entre as posições
de RC, máxima intercuspidação habitual e com a placa estabilizadora, confirmados por meio da análise do eixo horizontal
de rotação, as imagens não mostraram diferenças estatisticamente significantes entre as posições condilares. Assim,
pode-se concluir que as posições analisadas foram similares e
que a radiografia transcranial parece ser um método confiável
para análise da posição condilar.
INTRODUCTION
The position of the condyle in the mandibular fossa
and its clinical importance are fundamental in
restorative procedures. Some authors relate this
position to certain temporomandibular disorders
and alterations in the structures of the temporomandibular joint structures1,2.
The centric relation position, which has long been
used, has been defined in two different ways over
the years. The first is by authors who recommend a
more retruded position of the condyle3,4. Currently,
however, researchers maintain that the condyles are
in a more superior and anterior position in relation
to the posterior surface of the temporal bone5-7. Nev-
ertheless, TMJs are highly mobile joints, allowing
great capacity for adaptation and change in the position of the horizontal axis of rotation5,8. Moreover,
studies have shown that it is not a physiologic position because the muscles and ligaments comprised
in the system would be overloaded9,10. Other authors,
such as Weinberg11, believe that the condyles should
be centred in the fossa. Anatomical studies by Sicher12 show that the condyle should not compress the
retrodiscal area because it is profusely innervated
and vascularized.
When the condyle is positioned further back in the
mandibular fossa, it compresses the posterior edge of
the disc and can produce morphological alterations
Vol. 22 Nº 3 / 2009 / 155-162
Palavras chave: posição condilar, imagem por ressonância
magnética, relação cêntrica.
ISSN 0326-4815
Acta Odontol. Latinoam. 2009
156 Farley A. Venturelli, Paulo R. Junqueira Zuim, Rosse M. Falcón Antenucci, Alício R. Garcia
by thinning it13; during this stage, anatomical conditions favour displacement of the disc towards the
anterior region14. Depending on the structural tolerance of the retrodiscal tissues, small compressions,
which are not always able to produce morphological
alteration of the disc, may cause inflammation and
trigger local pain or pain referred to correlative sites8.
When it is concluded that function is not normal, a
diagnostic image is essential to assess why the
habitual bite is not the most functional bite. Diagnostic imaging has several advantages: it allows
reversible diagnosis, helps evaluate dental contacts
and the response of the system to the new condition
as time goes by, and enables it to be determined
whether the new treatment position is better for the
patient than his/her habitual maximum intercuspation (HMI)15.
Scientific literature has also shown that centric relation (CR) and centric occlusion (CO) positions
rarely coincide, i.e. when the mandible closes in
CR, in most people there is not a maximum number
of contacts between teeth16.
Several methods are used for studying condylar position. The most important of these include transcranial
radiography17, computer assisted tomography and
magnetic resonance imaging2. However, studies on
this issue have produced controversial results.
In view of the importance of the position of the
condyle in the fossa and the controversy in the literature, the aim of this study was to assess the
position of the condyle in the mandibular fossa in a
group of asymptomatic patients, when teeth are at
maximum intercuspation (MI), with a occlusal
splint and with a Lucia jig placed between the teeth,
by analyzing the horizontal axis of rotation in casts
mounted on an articulator, and by transcranial radiography and magnetic resonance imaging.
MATERIALS AND METHODS
This study was conducted on six young female
adults aged 19 to 25 years, who were free from signs
or symptoms of temporomandibular disorders and
had full dentition and Angle’s class I molar relation.
Three casts (two for the maxillary arch and one
mandibular) were made for each patient in special
stone plaster (Durone, Dentsply, Petrópolis, Rio do
Janeiro). One of the maxillary casts was used to
make the occlusal splint, while the other two were
used to determine the positions of the horizontal
axis of rotation using a semi-adjustable articulator.
To make the occlusal splint, a sheet of PVC 1.5 mm
thick was adapted to the maxillary cast under vacuum; the occlusal surface was rebased with
self-polymerizable resin (Artigos Odontológicos
Clássico, São Paulo) directly in the mouth of the
patient, and adjusted in order to distribute bilateral
contacts among all the teeth, and anterior disocclusion guides in eccentric movements.
Patients were instructed to wear it 24 hours a day.
Further adjustments of occlusion were made every
48 hours until mandibular equilibrium was
achieved, identified by the maintenance of the
occlusal contact points on the occlusal splint.
The casts were mounted on a semi-adjustable articulator, with the help of the facial arch and interocclusal
record in the CR position. To do this, a Lucia jig
was made from self-polymerizable resin (Duralay,
Reliance Dental Manufacturing, Worth, Illinois) on
the maxillary central incisors to prevent contact between antagonistic
teeth while the CR position was being
recorded, according to the technique
described by Bezzon & Orsi18.
To analyze the horizontal axis of
rotation, after mounting the casts,
an acrylic resin guide was made to
maintain the centric relation position between the casts. To do so, a
Buhnergraph19 for locating the horizontal axis of rotation graphically
was adapted to the lower member of
the articulator (Fig. 1).
Fig. 1: Buhnergraph adapted on the lower member and graph paper positioned
Statistical
analysis (analysis of variin the condylar device of the articulator while recording the horizontal axis of
ance
for
paired
samples with one
rotation in the centric relation position.
Acta Odontol. Latinoam. 2009
ISSN 0326-4815
Vol. 22 Nº 3 / 2009 / 155-162
Analysis of mandibular position
Fig. 2: Graph paper used for marking the points recorded for
the horizontal axis of rotation with the articulated casts in centric relation position (CR), habitual maximum intercuspation
(MIH) and with occlusal splint in position (PLACA).
variation factor) was done by comparing the differences between the right and left sides for the
distances corresponding to the CR and MI points
and with the occlusal splint.
When the device was ready, graph paper was fixed
to the lateral region of the condylar cavity, to mark
the horizontal axis of rotation in the CR position with
ink. Then the resin guide was removed and the casts
juxtaposed manually in the MI position. Another
point was marked in a different colour, corresponding to the mandibular horizontal axis of rotation in
the MI position. Finally, the occlusal splint was
placed on the maxillary cast and juxtaposed to the
mandibular cast, allowing a third point to be marked,
corresponding to the horizontal axis of rotation when
the occlusal splint was in place (Fig. 2). The distance
between the three points was measured using the
software AutoCAD 2000 (Autodesk Inc., USA).
Updegrave’s technique20 was then used to obtain
images of the TMJs with the occlusal splint
installed, with the Lucia jig in position (centric relation) and teeth in the HMI position. The radiographs
were scanned using AutoCAD 2000 software to
analyze the condylar position. A straight line was
drawn from the articular eminence (EA) to the squamotympanic fissure (FTC) on the digitalized TMJ
image. Another line was drawn from the highest
point of the roof of the mandibular fossa, perpendiVol. 22 Nº 3 / 2009 / 155-162
157
Fig. 3: Diagram of a TMJ. (EA) Articular eminence; (M) midpoint of the line between the squamotympanic fissure (FTC) and
the articular eminence; (A) distance from the front of the condyle
to the posterior surface of the articular eminence; (B) distance
from the top of the condyle to the roof of the fossa; (C) distance
from the condyle to the posterior surface of the mandibular fossa.
Fig. 4: Patient positioned in the device used for magnetic resonance imaging imaging of the left TMJ.
cular to the first, producing segment B. The intersection of the two lines was called point M.
Bisectors were drawn from point M into the anterior space, producing segment A, and into the
posterior space, producing segment C (Fig. 3).
The position of the condyle in the fossa was evaluated according to distances A, B and C (Fig. 4).
Magnetic resonance images were made using a
Picker Polaris machine with a 1.0 Tesla magnetic
field, repetition time (RT) 450 to 500 milliseconds
and echo time (ET) 20 milliseconds. The patient
was positioned and a unilateral surface coil located
over the joint to be examined (Fig. 4).
ISSN 0326-4815
Acta Odontol. Latinoam. 2009
158 Farley A. Venturelli, Paulo R. Junqueira Zuim, Rosse M. Falcón Antenucci, Alício R. Garcia
Table 1: Difference in millimetres (mm) between mandibular positions of the horizontal axis, between right (R)
and left (L) sides of the patients (PAT), analyzed using the semi-adjustable articulator.
PAT.
CENTRIC RELATION
TO MAXIMUM
INTERCUSPATION (MI)
CENTRIC RELATION
TO OCCLUSAL
SPLINT
OCCLUSAL SPLINT
TO MAXIMUM
INTERCUSPATION (MI)
R
L
R
L
R
L
1
2
3
4
5
6
1.9
1.3
0.8
1.4
0.6
0.8
0.9
0.6
0.8
1.3
0.9
0.5
1.3
0.7
0.0
1.3
1.2
1.5
2.0
0.6
0.0
1.8
0.9
0.9
1.8
1.7
0.8
1.8
1.0
1.2
1.6
1.4
1.2
1.6
0.9
0.8
MEANS
1.1
0.8
1.0
1.0
1.4
1.3
Three sequences of sagittal T1 weighted sections 2 mm
thick were made on each side of the patient, providing
a total six sequences for each patient studied: two (one
on each side), with the mouth closed and the occlusal
splint held between the teeth; two with the Lucia jig
and two with the teeth in HMI. The digital images were
analyzed with the AutoCAD 2000 software following
the same methodology as for radiographic images, and
the mean value was used for analysis.
The data were analyzed statistically using analysis of
variance for paired data because they were from the
same patients and had two variation factors, namely:
a) the imaging technique (resonance and transcranial radiography)
b) the position in which the image was taken (with
occlusal splint, with Lucia jig, and maximum intercuspation).
Each position (A, B and C) and each side (right and
left) of the patient was analyzed separately. Initially, no comparison was made between right and left
sides or between the distance from the anterior
region of the condyle of the fossa (Distance A) and
the middle and anterior regions (Distances B and C
respectively).
Student’s “t” test for paired samples was used to
compare the imaging of the patients’ right and left
sides.
Fig. 5.
Fig. 6.
Acta Odontol. Latinoam. 2009
RESULTS
Table 1 shows the distances of the horizontal axis
of rotation between positions CR, MI and with the
occlusal splint, as well as the differences between
right and left sides and the result of the statistical
analysis.
Table 2 and Fig. 5 show the mean distances (A, B
and C) obtained by the radiographic method for
patients’ right and left sides.
Table 3 and Fig. 6 show the mean distances (A, B
and C) obtained by magnetic resonance imaging for
patients’ right and left sides.
The results of the “t” test for paired simples showed
that there were no statistically significant differ-
ISSN 0326-4815
Vol. 22 Nº 3 / 2009 / 155-162
Analysis of mandibular position
159
Table 2: Sizes and means (M), in millimetres, of the distances between the condyle and the posterior surface of
the temporal bone (A); between the condyle and the roof of the mandibular fossa (B) and between the
condyle and the posterior surface of the mandibular fossa (C) for right side (RS) and left side (LS) of
patients (P) in the different positions analyzed – Transcranial radiography.
P
Maximum Intercuspation
RS
1
2
3
4
5
6
M
LS
TRANSCRANIAL RADIOGRAPHY
Occlusal Splint
RS
LS
Lucia Jig
RS
LS
C
B
A
C
B
A
C
B
A
C
B
A
C
B
A
C
B
A
2.2 4.4 3.6 2.2 4.4 3.7 2.3 4.4 3.5 2.9 4.3 4.0 2.4 4.4 3.6 2.5 4.4 4.0
1.9 2.1 3.2 1.5 2.2 2.9 1.7 1.7 2.8 1.6 1.7 2.4 1.8 1.7 2.7 1.5 1.6 2.2
3.5 3.3 2.0 3.4 2.9 2.0 3.2 3.2 2.2 3.2 3.1 1.5 3.2 3.2 2.5 3.1 3.2 1.5
1.7 3.1 1.9 2.0 2.7 1.9 2.0 3.0 1.4 1.9 2.5 1.4 1.9 2.9 0.7 1.9 2.6 0.9
3.1 3.0 1.5 2.2 3.4 2.2 3.3 4.3 3.6 2.7 3.1 2.0 3.0 2.6 1.0 2.3 3.2 2.0
2.0 2.1 2.4 1.6 1.5 2.0 2.0 2.1 2.4 1.6 1.5 2.0 2.0 2.1 2.5 1.6 1.5 1.9
2.40 3.00 2.43 2.15 2.85 2.45 2.41 3.11 2.65 2.31 2.70 2.21 2.38 2.81 2.17 2.15 2.75 2.08
Table 3: Sizes and means (M), in millimetres, of the distances between the condyle and the posterior surface of
the temporal bone (A); between the condyle and the roof of the mandibular fossa (B) and between the
condyle and the posterior surface of the mandibular fossa (C) on the right side (RS) and left side (LS) of
the patients (P) in the different positions analyzed. – Magnetic Resonance Imaging (MRI).
P
MAGNETIC RESONANCE IMAGING (MRI)
Maximum Intercuspation
Occlusal Splint
RS
1
2
3
4
5
6
M
LS
RS
LS
Lucia Jig
RS
LS
C
B
A
C
B
A
C
B
A
C
B
A
C
B
A
C
B
A
1.6 3.8 3.0 1.6 3.8 3.0 2.1 4.0 3.3 1.0 1.1 1.2 2.0 4.0 2.9 1.6 2.4 1.6
2.1 1.6 2.7 2.0 2.7 2.7 3.0 2.1 2.9 2.1 2.4 3.2 2.6 1.7 2.8 1.5 2.1 1.5
2.6 2.2 1.7 1.7 1.8 1.8 2.3 2.0 2.1 1.6 1.8 2.0 2.2 2.5 1.8 1.6 2.0 1.6
2.2 2.4 2.4 2.0 2.9 2.1 2.0 3.3 2.0 2.0 2.2 1.7 2.0 2.3 1.7 2.0 3.3 2.0
1.8 3.0 2.0 2.0 3.2 2.5 1.8 3.1 3.3 1.6 2.8 1.8 2.0 2.9 2.0 2.0 2.9 2.0
2.0 2.9 2.4 1.4 1.8 1.5 2.2 3.0 3.5 1.4 1.4 2.0 1.9 2.0 2.0 1.5 1.4 1.5
2.05 2.65 2.37 1.78 2.70 2.27 2.23 2.92 2.85 1.62 1.95 1.98 2.12 2.57 2.20 1.70 2.35 1.70
ences among the imaging techniques used, either
for distance A (t=0.02%), or distances B (t=2.46%)
and C (t=5.88%). Thus, statistically significant differences were found between patients’ right and left
sides for measurements A and B.
DISCUSSION
The position of the condyle in the mandibular fossa
for prosthetic work endeavouring to make the occlusal
condition re-establish mandibular equilibrium is still a
matter of much controversy11. Some studies show that
the position of the condyle in the mandibular fossa is
important5,21, and it seems to be one in which the
condyle is in a more superior and anterior position than
the posterior surface of the temporal bone.
Two different conditions need to be considered
regarding the position of the condyle. The first is
Vol. 22 Nº 3 / 2009 / 155-162
the position for mounting casts on the articulator in
order to make full dentures when the patient has lost
all dental references. in this case, the preferred position is centric relation, which can be reproduced.
The other condition is when occlusion is being rehabilitated in dentate or partially dentate patients. In
these cases, considering anatomical concepts, it is
best to mount the casts in a position of mandibular
equilibrium, which can match maximum intercuspation and is equal to the centric relation position when
gothic arch tracing is used in the determination. In the
position of mandibular equilibrium, joint structures
must be anatomically correctly positioned, the disc
must be juxtaposed to the condyle, and the condyledisc assembly is placed against the posterior surface
of the temporal bone, in agreement with the results of
the muscular forces of the elevator muscles8. Thus,
ISSN 0326-4815
Acta Odontol. Latinoam. 2009
160 Farley A. Venturelli, Paulo R. Junqueira Zuim, Rosse M. Falcón Antenucci, Alício R. Garcia
there must be enough space between the condyle and
the posterior surface of the fossa to hold the retrodiscal area, which is rich in vessels and nerves. In
addition, the masticatory muscles must be in harmony with the position, in which their fibres exert force
without producing alterations in the metabolism of
the muscle cells. To achieve this, the vertical dimension of occlusion needs to maintain the ideal muscle
length for the functions which require force, such as
crushing food. Finally, teeth must be in harmony with
these anatomical relations, with adequate overjet y
overbite to allow maximum intercuspation.
Our results showed that there is no statistically significant difference between sides of a patient when mean
values for the horizontal axis of rotation position are
compared between casts mounted in centric relation
and with occlusal splint. Even though the positions
are not very similar, they position the mandible in
equilibrium. However, when compared to habitual
maximum intercuspation, greater numerical differences are found between sides, suggesting that it is a
position of mandibular imbalance. Our results thus
suggest that although patients were asymptomatic,
they had some lateroprotrusive deviation, shown by
the differences between axes recorded in CR and MI
positions, indicating a slight orthopaedic imbalance,
though it was not enough to trigger temporomandibular disorders, probably due to high physiological
tolerance, as explained by Okeson8.
In addition to the position of the condyle, there is
much discussion regarding the methods and techniques used for analysis. This study showed no
significant difference between transcranial radiography and magnetic resonance imaging techniques for
analyzing the position of the condyle. These techniques may assist the clinician in complex restorative
procedures, such as cases of patients with some temporomandibular disorder, with occlusion as a
predisposing factor. However, the fact magnetic resonance imaging is expensive and that some patients
suffer claustrophobia may limit its use, and transcranial radiography may be a more practical choice.
The techniques differ in that magnetic resonance
imaging shows slightly smaller spaces between the
condyle and the temporal bone (articular space), as
it measures the real articular space, i.e. the space
between the soft tissues of the surfaces of the
condyle and the temporal bone22. In contrast, transcranial radiography shows the distance between
the compact bone tissue of the condyle and tempo-
Acta Odontol. Latinoam. 2009
ral bone structures23. The difference between the
space shown by transcranial radiography and magnetic resonance imaging in MI position, particularly
the anterior space (0.35 and 0.37 mm respectively
for right and left sides) found in this study might
indicate the thickness of the soft tissue, which is
variable, as shown in the study by Hansson et al.24.
and explanations by Mohl7: the thickest lining tissue is located at the anterior region of the condyle
and the posterior surface of the temporal bone,
where the highest incidence of forces occurs during
function. In this context, the distance between the
condyle and the posterior surface of the temporal
bone, analyzed by means of the two imaging techniques, showed that the condyles are usually closer
to the surface of the temporal bone.
The anterior position of the condyle in the fossa suggests that anterior displacement to the position of
maximum intercuspation occurs when the mandible
closes in centric relation. In this case, if the deviation is of the lateral protrusive type, it will position
the condyle further back on one side and further forward on the other. This condition is found in most
patients on analyzing the size of spaces A, B and C.
However, after using the occlusal splint, theoretically this difference should no longer exist. This does
not happen in any of the conditions used for positioning the condyles in the mandibular fossa, even
though no significant difference was found.
Statistical differences were found only between
sides when distances A and B were compared,
which may have been due to asymmetry between
sides in patients. Similarly, in the equilibrium position, the condyle is positioned in front of the centre
of the mandibular fossa, against the posterior surface of the temporal bone, as verified by Garcia21,
and maintains a posterior space for the retrodiscal
tissues, avoiding compression and inflammation8
or alterations of the posterior edge of the disc13,
which favour anterior displacement of the disc14.
When a occlusal splint is placed between the teeth,
there is decompression of the TMJ, as shown by
Kirk25. However, radiographic and resonance imaging did not show statistically significant differences.
This was to be expected in view of the fact that
asymptomatic patients without temporomandibular
disorders were selected. In these patients it was
assumed that occlusion, TMJ and muscles were in
orthopaedic balance, and that after the procedures
employed, no alterations would be observed.
ISSN 0326-4815
Vol. 22 Nº 3 / 2009 / 155-162
Analysis of mandibular position
Thus, the choice of mandibular position for occlusal
treatment of the patient will depend on whether or
not there are teeth and temporomandibular disorders. If the patient is asymptomatic, like the ones
selected for the study, the treatment can be conducted in the habitual maximum intercuspation position.
However, if the patient has some disorder it is advisable to initially re-establish mandibular equilibrium
by means of a occlusal splint, to find out whether
the occlusal condition is harmonious with the
resulting muscular forces.
When occlusal discrepancy is great, it is advisable
to adjust the occlusion, enabling the teeth to occlude
in the maximum intercuspation position, which, in
our opinion, is an adequate condition of mandibular balance for the treatment. Subsequently, the
casts can be juxtaposed or the position of the
mandible recorded for mounting in MI position in
order to rehabilitate the teeth.
161
CONCLUSION
Based on the results obtained from the techniques
proposed in this study, it can be concluded that:
a) The analysis of the horizontal axis of rotation,
when the centric relation position was compared to
the position recorded with the occlusal splint and at
maximum intercuspation, showed symmetrical differences between the means for the two sides of the
patient.
b) The analysis of radiographic and magnetic resonance images showed statistically significant
difference in the position of the condyle with relation to the posterior surface of the temporal bone,
roof and posterior surface of the mandibular fossa,
for both sides of the patient.
c) Although the transcranial radiography analyzes
the lateral pole region, it seems to be a reliable
method for analyzing the position of the condyle in
the mandibular fossa.
CORRESPONDENCE
Prof. Adj. Alício Rosalino García
Rua José Bonifácio,1193 – Vila Mendonça,
CEP 16015-050, Araçatuba-São Paulo.
e-mail: [email protected]
REFERENCES
1. Ozawa S, gaeert b, kawata t, tanimoto K, Tanne K. Reconsideration of the TMJ condylar position during internal
derangement: comparison between condylar position on
tomogram and degree of disk displacement on MRI. Cranio
1999;17:93-100.
2. Rammelsberg P, Jäger L, Duc JM. Magnetic resonance imaging-based joint space measurements in temporomandibular
joints with disk displacements and in controls. Oral Surg
Oral Med Pathol Oral Radiol Endod 2000;90:240-248.
3. McCollum BB. The mandibular hinge axis and a method of
locating it. J Prosthet Dent 1960;10:428-435.
4. Posselt U. Fisiología de la oclusión y rehabilitación. 2 ed.
Barcelona: JIMS, 1973. 352 p.
5. Celenza FV. The centric position: replacement and character. J Prosthet Dent 1973;30:591-598.
6. Dawson PE. Avaliação, diagnóstico e tratamentos dos problemas oclusais. São Paulo: Artes Médicas, 1980. 405p.
7. Mohl ND, Zarb GA, Carlsson GE. et al. Fundamentos de
oclusão. Rio de Janeiro: Quintessence, 1989.
8. Okeson JP. Tratamento das desordens temporomandibulares. 4ta ed. São Paulo: Artes Médicas, 2000. 500p.
9. Moyers RE. Some physiologic considerations of centric and
other jaw relations. J Prosthet Dent 1956;6:183-194.
10. Jankelson B. Neuromuscular aspects of occlusion. Effects
of oclusal position on the physiology and dysfunction of
the mandibular musculature. Dent Clin North Am 1979;
23:157-168.
Vol. 22 Nº 3 / 2009 / 155-162
11. Weinberg LA. Posterior bilateral condylar displacement: its
diagnosis and treatment. J Prosthet Dent 1976; 36:426-440.
12. Sicher H. Structural and functional basis for disorders of
the temporomandibular articulation. J Oral Surg 1955;13:
275-279.
13. Westesson PL, Bronstein SL, Liedberg J. Internal derangement
of the temporomandibular joint: morphologic description with
correlation to joint function. Oral Surg Oral Med Oral Pathol
1985;59:323-331.
14. Farrar WB. Characteristcs of the condylar path in internal
derangements of the TMJ. J Prosthet Dent 1978;39:319-323.
15. Keller DC. Diagnostic orthotics to establish the functional
mandibular-maxillary relation for orthodontic corrections.
J Gen Orthod 2001;12:21-25.
16. Cordray FE. Three-dimensional analysis of casts articulated in the seated condylar position from a deprogrammed
asymptomatic population: a prospective study. Part 1. Am J
Orthod Dentofacial Orthop 2006;129:619-630.
17. Weinberg LA. An evaluation of duplicability of temporomandibular joint radiographs. J Prosthet Dent 1970;24:
512-541.
18. Bezzon OL, Orsi IA. An interocclusal record made of a
combination of wax and acrylic resin. J Prosthet Dent 1994;
72:334-336.
19. Long JH Jr. Location of the terminal hinge axis by intraoral
means. J Prosthet Dent 1970;23:11-24.
20. Updegrave WJ. An evaluation of temporomandibular joint
roentgenography. J Am Dent Assoc 1952;46:408-419.
ISSN 0326-4815
Acta Odontol. Latinoam. 2009
162 Farley A. Venturelli, Paulo R. Junqueira Zuim, Rosse M. Falcón Antenucci, Alício R. Garcia
21. Garcia AR. Avaliação clínica e radiográfica de posições
condilares e recastamento articular decorrentes da perda de
dentes posteriores e interferências oclusais em pacientes
com disfunção da articulação temporomandibular, 91 f.
Tese (Doutorado) - Faculdade de Odontologia, Universidade Estadual Paulista, Araçatuba, 1993.
22. Emshoff R, Innerhofer K, Rudisch A, Bertram S. Relation
between temporomandibular joint pain and magnetic resonance imaging findings of internal derangement. Int J Oral
Maxillofac Surg 2001;30:118-122.
Acta Odontol. Latinoam. 2009
23. Leary JM, Johnson WT, Harvey BV. An evaluation of temporomandibular joint radiographs. J Prosthet Dent 1988;
60:94-97.
24. Hansson T, Oberg T, Carlsson GE, Kopp S. Thickness of
the soft tissues layers and the articular disk in the temporomandibular joint. Acta Odontol Scand 1977;35:77-83.
25. Kirk WS Jr. Magnetic resonance imaging and tomographic
evaluation of occlusal appliance treatment for advanced
internal derangement of the temporomandibular joint. J
Oral Maxillofac Surg 1991;49:9-12.
ISSN 0326-4815
Vol. 22 Nº 3 / 2009 / 155-162